AMA CPT® Assistant - 1998 Issue 1 (January)

Documentation Guidelines, Correlating Exam Level to Documentation (Q&A) (January 1998)

January 1998 page 11c Coding Consultation Documentation Guidelines, Correlating Exam Level to Documentation (Q&A) Must a physician indicate in the medical record which exam is being used so a reviewer would know which bulleted exam elements would be required for a given level of exam? AMA Comment CPT code reporting is based on the documentation submitted. If the documentation substantiates a particular level, reporting is correlated accordingly. Documentation Guidelines, Correlating Exam Level to Documentation (Q&A). CPT® Assistant. 1998; January 1998 page 11c ...

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